Chapter 1: National reform
The mental health and suicide prevention landscape has continued to evolve since the release of the National Mental Health Commission's (the Commission's) Monitoring mental health and suicide prevention reform: National Report 2019 , including the establishment of two national leadership roles (Box 1).
Key findings from major inquiries and investigations into mental health and suicide prevention have or are due to be released, and progress has been made on the majority of the National Report 2019 recommendations. The national discourse on mental health has not been limited to mental health–specific activities; inquiries into aged care, disability and domestic violence have highlighted significant mental health impacts on some of our most vulnerable cohorts. The message from these and other activities is clear: mental health and suicide prevention are issues for all governments, decision makers across all sectors, and all communities.
Box 1: New national roles
In February 2020, the Prime Minister announced a new National Commissioner for Defence and Veteran Suicide Prevention. This will operate as a permanent independent body to investigate, and support the prevention of, suicide among serving and ex-serving Australian Defence Force members. In November 2020, Dr Bernadette Boss CSC commenced as the interim National Commissioner for Defence and Veteran Suicide Prevention.
In May 2020, a Deputy Chief Medical Officer for Mental Health role was created to strengthen the coordinated medical and mental health response and decision making in relation to the COVID-19 pandemic, and support the delivery of mental health system reforms for all Australians. Dr Ruth Vine was appointed as Australia's first Deputy Chief Medical Officer for Mental Health.
In October 2020, National Cabinet announced a new Mental Health National Cabinet Reform Committee. The committee will deliver a new National Mental Health and Suicide Prevention Agreement by November 2021. It will also oversee, and provide advice to National Cabinet on, the implementation of the National Mental Health and Wellbeing Pandemic Response Plan, which guides jurisdictions' responses to COVID-19.
In December 2020, the Hon David Coleman MP was sworn in as Assistant Minister to the Prime Minister for Mental Health and Suicide Prevention.
Update on National Report 2019 recommendations
The National Report 2019 included 30 recommendations to improve the mental health and suicide prevention system. The Commission is pleased to see progress on some of these recommendations despite the disruption caused by the 2019–20 summer bushfires and the COVID-19 pandemic. Of the 30 recommendations, four have been completed, 17 are progressing, four are pending the Australian Government's response to the Productivity Commission inquiry into mental health, and five have not been progressed. The lack of progress on these five recommendations is mostly due to the changing landscape of mental health; the recommendations will be considered in line with the recommendations from the Productivity Commission (discussed below). A detailed progress update on the National Report 2019 recommendations is provided in Appendix A.
Progress has been made on Commission recommendations to address population data gaps and improve data collection for mental health and suicide prevention. In particular, the Commission welcomes the forthcoming update of national prevalence data through the National Survey of Mental Health and Wellbeing (discussed in Section 1, Chapter 2). The Commission also welcomes the routine analysis and publication of psychosocial risk factors associated with suicide deaths, which have been funded as part of the National Suicide and Self-harm Monitoring System project (discussed in Section 1, Chapter 2).
The National Disability Insurance Agency (NDIA), the Australian Government, and state and territory governments have been working to improve the experiences of people with psychosocial disability who access the National Disability Insurance Scheme (NDIS).
The introduction of the NDIS recovery coach, and enhanced roles for Partners in the Community and Community Connectors are important steps to help people with psychosocial disability access appropriate support and navigate the NDIS.
Concerns have been noted about access to the NDIS and transition arrangements for people with psychosocial disability. The routine release of data on NDIS participants with psychosocial disability has led to increased transparency. Together with evaluation of the transition measures for people transitioning into the NDIS, this provides important evidence on the extent to which people with psychosocial disability are receiving the support they need both within and outside the NDIS. Psychosocial disability and the NDIS are discussed further in Section 1, Chapter 3.
A number of developments have also occurred for Primary Health Networks (PHNs). The Australian Government Department of Health has released the 2018–19 PHN Program Performance and Quality Framework report, which provides baseline data on PHN performance. The Department of Health is also working in collaboration with PHNs and the National Aboriginal Community Controlled Health Organisation to review the current guiding principles of these organisations.
Some of the Commission's recommendations from the National Report 2019 for suicide prevention have progressed, and the majority are likely to be captured by final advice from the National Suicide Prevention Adviser. The Australian Government has funded the expansion of aftercare services for those who have self-harmed or attempted suicide, new postvention services to support families and carers who have been bereaved by suicide, youth peer support, and support for Aboriginal and Torres Strait Islander youth through the Pilbara trial and headspace services. Developments in suicide prevention are discussed further in Section 1, Chapter 3.
National inquiries and activities
National inquiries and activities into mental health and suicide prevention have provided thousands of people and organisations with the opportunity to share their hopes and visions for reform, as well as their frustration, grief and at times anger with systems that often seemed broken. The following inquiries handed down reports documenting these stories and recommendations for reform.
Productivity Commission inquiry into mental health
The Productivity Commission inquiry into mental health has been described as a ‘once in a lifetime opportunity to reform the mental health system. The inquiry was given a broad remit to consider the effect of supporting mental health on economic and social participation, productivity and the Australian economy; how sectors beyond health can contribute to improving mental health; the effectiveness of current programs and initiatives; and whether current investment in mental health is delivering the best outcomes.
The final report was released on 16 November 2020. It reflects many of the recommendations made by the Commission in its submissions to the inquiry and in the National Report 2019—in particular, for a cross-portfolio and whole-of-government approach to mental health and suicide prevention, priority investment in early intervention and recovery, and clarification of funding arrangements for mental health services. Recommended reforms to build a person-led mental health system were made across five broad areas:
- • prevention and early intervention by focusing on children's wellbeing across the education and health systems, supporting the social inclusion of people living with mental illness, and taking action to prevent suicide
- • recovery-focused health care by increasing informed access to mental health care, expanding supported online treatment, bridging mental health care gaps, improving crisis care and improving outcomes for people with comorbidities
- • reorienting supports and services beyond health by improving the availability of psychosocial supports, providing supportive housing and homelessness services, and improving mental health outcomes for people in the justice system
- • improving training and work by supporting youth economic participation, equipping workplaces to be mentally healthy, and tailoring income and employment support
- • enabling reform by providing integrated care; supporting and involving families and carers; strengthening the mental health workforce; ensuring best-practice governance; providing funding; and commissioning and improving monitoring, evaluation and research.
Specifically, the Productivity Commission's final report articulated key roles and responsibilities by recommending the following:
- • The Australian Government should involve carers and consumers in all elements of system governance and reform.
- • The number of sessions provided through the Medicare Benefits Schedule (MBS) should be increased. The suite of online low-intensity services should be evaluated, and a cross-portfolio approach to mental health should be facilitated.
- • State and territory governments should increase community ambulatory, bed-based services and aftercare, and provide alternatives to emergency department presentations for people suffering emotional distress.
- • A whole-of-government approach is needed to prevention and early intervention across a range of institutions (for example, schools, tertiary education, workplaces), and linking mental health services with social services.
- • The Commission should be responsible for evaluating mental health (and non-health) programs, developing and driving a national strategy to reduce stigma and discrimination, and monitoring and reporting on cooperation between PHNs and Local Health Networks (LHNs) for regional planning and implementation.
Following the release of the final report, the Australian Government opened a three-month consultation for the public and key stakeholders to provide additional feedback on the report. The Australian Government will respond to the Productivity Commission's final recommendations in the context of the May 2021 Budget.
National Suicide Prevention Adviser's interim advice
The National Suicide Prevention Adviser's interim advice was released on 16 November 2020. The interim advice captures the voices of people with first-hand experience of suicidal distress, as well as carers, people bereaved by suicide, representatives of government and suicide prevention experts. It highlights the need for a cross-portfolio approach to reduce and respond to distress.
The interim advice calls for a comprehensive, coordinated and compassionate response that addresses vulnerabilities and provides supports long before a crisis emerges.
The report included a range of 'in principle' recommendations, which formed the basis of government and sector consultations ahead of the final advice, which was delivered to the Australian Government in December 2020.
As with the Productivity Commission's inquiry, the interim advice calls for a national whole-of-government approach to suicide prevention. Its 13 in-principle recommendations provide a path for implementing this approach. The interim advice acknowledges that suicide prevention has generally been the responsibility of health departments, but that evidence shows that a broader focus is required to ensure that we can address the social and economic drivers of distress, and assist people as early as possible, building social connection and support.
The interim advice highlights that suicide prevention would benefit from involvement of the Prime Minister and premiers to provide this whole-of-government focus. It calls for development of a national suicide prevention strategy, a suicide prevention workforce plan, integration of lived experience knowledge, and improved data and evidence to inform decision making. It also emphasises the importance of targeted and coordinated approaches that meet the needs of priority populations.
Vision 2030: blueprint for the future
Vision 2030 is a long-term blueprint for a successful, connected and well-functioning mental health and suicide prevention system that meets the needs of the whole community. The development of Vision 2030, led by the Commission, began with consultations through the Connections project that sought the views of people with a wide range of experiences and from different stages in life on their experience with the mental health system.
This provided the opportunity for the Commission to hear at the local level what was happening, what was working and what needs to change.
Vision 2030 is consistent with the recommendations and approach of the Productivity Commission's inquiry into mental health, and other national, and state and territory inquiries that are underway. Vision 2030 provides a strategic framework through which current recommendations and future strategies and plans can be viewed.
Royal Commission into Victoria's Mental Health System
The Royal Commission into Victoria's Mental Health System was established in 2019 to provide the community with a clear and ambitious set of actions that would change Victoria's mental health system, and enable Victorians to experience their best mental health now and in the future. This commitment acknowledged that psychological distress and mental illness are significant health and social issues, and that the current mental health system is not sufficiently meeting the needs of Victorians.
The Royal Commission's interim report was released in November 2019 and included nine priority recommendations to be addressed immediately by the Victorian Government. The mental health sector has welcomed the report's openness about the extent of problems within the existing system, as well as an acknowledgement of the harms these problems can cause. There was a positive response to recommendations to increase acute mental health beds, fund all area mental health services to offer the Hospital Outreach Post-suicidal Engagement program, establish a Collaborative Centre for Mental Health and Wellbeing, and expand the consumer and family–carer lived experience workforces. However, the report was also criticised for failing to sufficiently address issues around housing and homelessness, and the specific experiences of women and girls.
The interim report's views about the need for a person-led mental health system align with the reform agenda to be outlined in Vision 2030.
The Royal Commission has indicated that much broader, sweeping reform actions are required to redesign a failing system and that these will be advanced in the final report, which is due in early 2021.
The Royal Commission is expected to result in significant reform—the Victorian Government has already established Mental Health Reform Victoria to implement seven of the nine priority recommendations and has committed to implementing all the interim report's recommendations.
Royal Commission into Aged Care Quality and Safety
The Royal Commission into Aged Care Quality and Safety (Aged Care Royal Commission) was established on 8 October 2018 to investigate the quality of aged care services currently being delivered to older Australians in the community and in residential aged care facilities. An overview of the aged care system is provided in Box 2. The Aged Care Royal Commission delivered an interim report on 31 October 2019, and a final report is due by 26 February 2021.
The interim report, titled Neglect, highlighted a number of opportunities for aged care reform. One area highlighted was the lack of access to appropriate mental health care for residents in residential aged care facilities. The interim report recommended the need for strong linkages between aged care service providers and more specialised services to assist older people who need additional services, such as specialist mental health services. For many older people, deteriorating mental health can be overlooked as dementia or general cognitive decline, with low visibility of the underlying causes of depression and other mental illness. The aged care workforce requires more education on the effects of aging with regard to the mental health needs of older people, suicide prevention, and the behavioural and psychological symptoms of dementia, from mild to severe.
The Commission provided a preliminary response to the Aged Care Royal Commission draft propositions.
This indicated that having an aged care workforce skilled and trained in mental health literacy is essential as a core competency for all residential aged care facility staff within the first year of employment.
The Aged Care Royal Commission's draft propositions, which were discussed at its mental health hearing, had a strong clinical focus on access to, and delivery of, services. Whereas this approach may be appropriate for those who are experiencing severe mental illness, most people would benefit from a more holistic approach to their mental health and wellbeing. The Commission recommends an approach based on the Contributing Life Framework, which provides a whole‐of‐person, whole‐of‐system, whole‐of‐life framework to mental health and wellbeing. This approach would include the expansion of programs, outside of clinical services, to contribute to the mental health and wellbeing of older people, such as 'befriending' programs, and an enhanced role for peer workers in both community and residential aged care settings.
Box 2: Overview of the aged care system
Most people who reach older age in Australia will require care and support, either from family members or from the formal aged care system. Around 80% will access some form of government-funded aged care during their life. The majority receive home-based care and support; few live in an aged care home. Yet, as noted by the Aged Care Royal Commission, the prevalent media and community debate is focused on residential aged care, and indeed mainly on any quality failures that occur there.
In 1997, the Australian aged care system was restructured into one system, providing a continuum of care; funding and regulation is now predominantly the responsibility of the Australian Government. A further reform occurred as part of the National Health Reforms in 2010, when the states and territories agreed to transfer responsibility for community care services for older people delivered under the Home and Community Care Program to the Australian Government.
Overall spending on aged care services is forecast to grow from $18.0 billion in 2018–19 to $22.1 billion in 2021–22.
Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability
The Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability (Disability Royal Commission) was established in April 2019 in response to community concern about widespread reports of violence against people with disability, and their neglect, abuse and exploitation. The Disability Royal Commission has been tasked with looking at ways to:
- • prevent and better protect people with disability from experiencing violence, abuse, neglect and exploitation
- • achieve best practice in reporting, investigating and responding to violence, abuse, neglect and exploitation of people with disability
- • promote a more inclusive society that supports people with disability to be independent and live free from violence, abuse, neglect and exploitation.
In its interim report, released on 30 October 2020, the Disability Royal Commission indicated that it had received a number of submissions that highlighted the difficulties people with disability face in navigating the mental health sector. Submissions have reported the use of seclusion and physical restraint to manage mental health in people with disability. The Commission's submission provided evidence from its collaborative work in 2017 and 2018 with the Australian College of Mental Health Nurses to promote best practice in reducing use of restrictive practices in mental health services.
People with psychosocial disability continue to require mainstream services such as health care, education, housing and transport.
The Commission supports continued efforts to ensure that mainstream services are not only accessible to people with psychosocial disability, but are also inclusive, person led, and free from stigma and discrimination.
Progress should be made to eliminate stigma and discrimination because they restrict access to social and community resources relevant to good health and expose individuals to more toxic environments, which in turn further erode the health of those being stigmatised.
The Disability Royal Commission's interim report highlighted systemic challenges in providing health care over a person's lifetime, including preventive and mental health care.
Royal Commission into National Natural Disasters Arrangements
The Royal Commission into National Natural Disasters Arrangements (Natural Disasters Royal Commission), established on 20 February 2020, released its report on 28 October 2020. The report looked at all aspects of emergency management and made two recommendations on mental health: for all governments to develop consistent and compatible methods for measuring the health and mental health impacts of natural disasters, and for governments to take steps to ensure that this data is shared.
The Natural Disasters Royal Commission heard during the inquiry that often services were brought in temporarily, which did not allow continuity of care or development of long-term community-based mental health care.
The Royal Commission therefore recommended that all governments should support localised planning and delivery of mental health services. The findings are discussed further in Section 2.